2 Free Issues

Follow

What Pregnancy Is Like in Nepal

Nepal is seen as a success story in the maternal health, one of just a few countries to significantly lower the number of women dying in childbirth. Still, until the status of women in society improves, childbirth will remain perilous.

Lalu Nepali, 30, nine months pregnant, gathers kindling for fire near her home in Rima, Achham, in the far western region of Nepal, December 17, 2012 (Allison Shelley)

In the slanted golden light of late afternoon, Lalu Nepali beat rice with a long wooden mallet. The wood extended a foot above her head, and she dropped it onto her pile of grains, separating rice from the hulls with a rhythmic thud, thud, thud. A white scarf was wrapped tightly around her midsection as if to hold in her nearly bursting belly. She grunted at the exertion with each strike. Thud, grunt, thud, grunt. Nine months pregnant, she was due any day.

Nepal is viewed as one of the success stories in the global effort to improve women's chances in pregnancy and delivery. The United Nations created the Millennium Development Goals to measure improvements in various aspects of life in developing countries, and the fifth goal is to reduce by 75 percent the rate of women dying around pregnancy and delivery by 2015. Almost nowhere has this been accomplished, as changing birth outcomes has proven more challenging than anticipated.

Nepal is one of just a few countries that has already significantly reduced maternal deaths, and is on track to achieve MDG 5. But investments in the health system are crippled by engrained gender disparity. Until the status of women improves, childbirth will remain a dangerous labor.

"The hospital told me not to work, but what can be done?"

The Nepali government has worked hard to improve their maternal health statistics, and arranged national policy around the international development agenda. There is a rigorous family planning program which has helped lower the average number of children women have from 4.6 in 1996 to 2.6 in 2011. Government spending on health tripled between 2006 and 2011. Abortion was legalized and reproductive rights were specifically included in the interim constitution of 2007, and more women are birthing in health centers, motivated in part by a government program that pays women to birth in clinics.

Lalu lives deep in Far-Western Nepal, a two-day's drive and a world away from the bustling capitol where health policy is hammered out. Her village is stacked in tiers on the edge of a mountain, jutting over a deep valley. Across Achham, the endless hills are carved into terraces of fields planted with potato and wheat seedlings.

To get to her local clinic Lalu had to walk one to two hours, depending on her pain, along a path cut out of the side of the mountain, slowly ascending to the main dirt road. Then she had to double back on the opposite face of the mountain, descending a slippery, pebble strewn path. The health post is off the main road, past a tiny town comprised of teashops selling little more than hard candies and instant noodles. A steep, rocky path leads down to the clinic; it feels like a landslide waiting to happen.

But Lalu made the trek several times throughout her pregnancy to take advantage of prenatal checkups, and the 100 Nepali Rupees ($1.03 USD) she earned for each visit. A central part of Nepal's efforts to make labor safer has been to entice women to birth in clinics and hospitals. At Lalu's local clinic, a fresh-faced midwife named Parvati Kayat has received laboring women desperately trying to reach the health clinic to get the seemingly nominal stipend. "Some women are so poor that even if they deliver on the way they struggle to get here just to get the 1,000 Rupees ($10.57)," she said. The program pays between 500 and 1,500 Nepali Rupees, or $5 to $15 USD, depending on the region.

Please use a JavaScript-enabled device to view this slideshow

Lalu planned to birth at the clinic this time, something other women in her village had started doing in the past few years. "Everybody says it's more comfortable there," she explained.

Survival, not comfort, was her priority in earlier births. Most women in her village can relate a horrible birth story of their own, or a relative's near-death experience during birth. It makes for anxious pregnancies, and inspired Nepal's women's health activists to push for policy change.

Women in this part of Nepal practice a tradition called chaupadi where each month they segregate themselves from their families during menstruation. Menstrual blood is considered impure and allowing women in the house is believed to bring devastating bad luck.

In the village, most homes are two stories, made of wood beams and mud. Upstairs are the bedrooms and the kitchen, set off from a balcony that serves as a hallway, terrace, and clothesline. Downstairs is the stable; the ground is covered in straw to soak up pools of excrement from the cows and buffalo. When women are menstruating, and historically when they gave birth, they stayed downstairs, next to the cattle, in grimy rooms that would not be tainted by their blood (even so, the rooms were purified after the birth or at the end of menstruation).

Women birthed alone or with the help of female relatives or traditional midwives, so women prayed and hoped for a simple labor, because if there were complications there was often little to be done. At the last count, three quarters of women in the Far Western Hill region still gave birth at home.

Lalu had two surviving daughters, but in between there had been a son. He was born in the stable, in a long and painful delivery, but he was breach and while his body emerged, his head was stuck in the birth canal for hours. By the time he was born he was dead; Lalu also nearly died.

Her husband stayed seated as Lalu grunted and panted her way through her chores.

Lalu's decision to follow her neighbors and birth in the clinic shows the implications of Nepal's investments in maternal health, but Kayat, the midwife, said she still only sees between 10 and 14 births per month. And she said there is little comprehension among the women about the importance of birthing in the clinic's somewhat dark and dingy "DELIVARY ROOM" (as it is labeled). "There are a few women who understand that due to excessive bleeding they can die, so they should deliver here," Kayat said, "but the majority just come for the money."

Kayat and other health professionals see a deeper social issue underlying Nepal's lingering maternal health challenges. Kayat works with women she sees as high risk, jeopardized by poor nutrition and manual labor. "I tell them don't carry a heavy load, take as much rest as possible, eat green vegetables, yellow fruits, legumes, and beans." But, she admitted, "women don't have a voice. It feels bad. Some women say they eat, but their weight says something else ... some women, when I counsel them ask 'how can I get those things? Where can I get those?'"

"This is not only a health problem, this is also an empowerment issue, a gender problem," explained Samita Pradhan, a women's rights activist at the Centre for Agro-Ecology and Development in Kathmandu. Nepal ranks 157th out of 186 countries on the United Nation's Gender Inequality Index, and women in the Far West have the least say in household decisions of any region in the country. A government study of the maternal health program found the most births taking place in health centers occurred in areas of the country where women were more empowered and more economically stable.

Throughout her pregnancy, Lalu was consistently doing some kind of physical labor; chopping wood with an axe, vigorously bathing her daughter, lugging huge piles of firewood, cooking dinner in a smoke clogged kitchen. She worried about her baby and about incessant pain in her side. "The hospital told me not to work, but what can be done?" she asked. "Even if I can't work I have to." Lalu said there was no one to help her, "there is one old mother-in-law and my young daughter, no one else."

Most times I saw Lalu, her husband Ghagane Nepali was also there, seated in the yard, sometimes helping the children study, sometimes working with his sewing machine, practicing to become a tailor. In this remote village gender roles are so entrenched that it was inconceivable for Ghagane to do household labor -- considered women's work -- even with his wife nine months pregnant.

While Lalu physically kept the household going, Ghagane's role was to provide for the family. But in Achham there is almost no employment for men; the village is full of women, boys, and the elderly or sick. The healthy men in town are listless migrants on vacation, with nothing to do between trips to India where they work exhausting hours for little pay and pile into cramped rooms with other transitory laborers.

Related Story

Ghagane recently returned home himself. He was the only man of his generation living in the family compound. "I came back because we should have at least one brother at home," he said. "I like Nepal but if you want to support your family you have to go to India." Many of the men who return home while away their time, showing off new cell phones bought abroad and drinking tea, but Ghagane was more industrious and was trying, with his sewing machine, to find some way to be productive for the family. But despite his work ethic, he stayed seated as Lalu grunted and panted her way through her chores.

"Pregnancy and after delivery is a very critical time for women. If they are taken care of, they will be prevented from so many problems, but even [during] those periods they have to carry firewood, cow dung, manure, all that. They can't say 'I am pregnant,' or 'I am menstruating,' or 'I have a small child.' They have no voice at all," explained Pradhan, the activist in Kathmandu. "It's very complex, only health [policy] cannot address this issue ... maternal health issues [are] related to social issues"

Lalu ended up birthing a healthy son at the clinic. She is part of Nepal's success story: in her lifetime she moved from birthing alone in a stable to birthing with a trained midwife at a clinic, and she survived. But her role in the home and her physical labor until the last moment point to the underlying issues Nepal will have to address to broaden women's chances for health.

About the Authors

Allyn Gaestel is a freelance journalist based in Port-au-Prince, Haiti, who writes on international politics, social issues, and human rights. She is a former United Nations correspondent and National Press Foundation Fellow.

Most Popular

Should you drink more coffee? Should you take melatonin? Can you train yourself to need less sleep? A physician’s guide to sleep in a stressful age.

During residency, Iworked hospital shifts that could last 36 hours, without sleep, often without breaks of more than a few minutes. Even writing this now, it sounds to me like I’m bragging or laying claim to some fortitude of character. I can’t think of another type of self-injury that might be similarly lauded, except maybe binge drinking. Technically the shifts were 30 hours, the mandatory limit imposed by the Accreditation Council for Graduate Medical Education, but we stayed longer because people kept getting sick. Being a doctor is supposed to be about putting other people’s needs before your own. Our job was to power through.

The shifts usually felt shorter than they were, because they were so hectic. There was always a new patient in the emergency room who needed to be admitted, or a staff member on the eighth floor (which was full of late-stage terminally ill people) who needed me to fill out a death certificate. Sleep deprivation manifested as bouts of anger and despair mixed in with some euphoria, along with other sensations I’ve not had before or since. I remember once sitting with the family of a patient in critical condition, discussing an advance directive—the terms defining what the patient would want done were his heart to stop, which seemed likely to happen at any minute. Would he want to have chest compressions, electrical shocks, a breathing tube? In the middle of this, I had to look straight down at the chart in my lap, because I was laughing. This was the least funny scenario possible. I was experiencing a physical reaction unrelated to anything I knew to be happening in my mind. There is a type of seizure, called a gelastic seizure, during which the seizing person appears to be laughing—but I don’t think that was it. I think it was plain old delirium. It was mortifying, though no one seemed to notice.

Why the ingrained expectation that women should desire to become parents is unhealthy

In 2008, Nebraska decriminalized child abandonment. The move was part of a "safe haven" law designed to address increased rates of infanticide in the state. Like other safe-haven laws, parents in Nebraska who felt unprepared to care for their babies could drop them off in a designated location without fear of arrest and prosecution. But legislators made a major logistical error: They failed to implement an age limitation for dropped-off children.

Within just weeks of the law passing, parents started dropping off their kids. But here's the rub: None of them were infants. A couple of months in, 36 children had been left in state hospitals and police stations. Twenty-two of the children were over 13 years old. A 51-year-old grandmother dropped off a 12-year-old boy. One father dropped off his entire family -- nine children from ages one to 17. Others drove from neighboring states to drop off their children once they heard that they could abandon them without repercussion.

His paranoid style paved the road for Trumpism. Now he fears what’s been unleashed.

Glenn Beck looks like the dad in a Disney movie. He’s earnest, geeky, pink, and slightly bulbous. His idea of salty language is bullcrap.

The atmosphere at Beck’s Mercury Studios, outside Dallas, is similarly soothing, provided you ignore the references to genocide and civilizational collapse. In October, when most commentators considered a Donald Trump presidency a remote possibility, I followed audience members onto the set of The Glenn Beck Program, which airs on Beck’s website, theblaze.com. On the way, we passed through a life-size replica of the Oval Office as it might look if inhabited by a President Beck, complete with a portrait of Ronald Reagan and a large Norman Rockwell print of a Boy Scout.

Since the end of World War II, the most crucial underpinning of freedom in the world has been the vigor of the advanced liberal democracies and the alliances that bound them together. Through the Cold War, the key multilateral anchors were NATO, the expanding European Union, and the U.S.-Japan security alliance. With the end of the Cold War and the expansion of NATO and the EU to virtually all of Central and Eastern Europe, liberal democracy seemed ascendant and secure as never before in history.

Under the shrewd and relentless assault of a resurgent Russian authoritarian state, all of this has come under strain with a speed and scope that few in the West have fully comprehended, and that puts the future of liberal democracy in the world squarely where Vladimir Putin wants it: in doubt and on the defensive.

The same part of the brain that allows us to step into the shoes of others also helps us restrain ourselves.

You’ve likely seen the video before: a stream of kids, confronted with a single, alluring marshmallow. If they can resist eating it for 15 minutes, they’ll get two. Some do. Others cave almost immediately.

This “Marshmallow Test,” first conducted in the 1960s, perfectly illustrates the ongoing war between impulsivity and self-control. The kids have to tamp down their immediate desires and focus on long-term goals—an ability that correlates with their later health, wealth, and academic success, and that is supposedly controlled by the front part of the brain. But a new study by Alexander Soutschek at the University of Zurich suggests that self-control is also influenced by another brain region—and one that casts this ability in a different light.

Modern slot machines develop an unbreakable hold on many players—some of whom wind up losing their jobs, their families, and even, as in the case of Scott Stevens, their lives.

On the morning of Monday, August 13, 2012, Scott Stevens loaded a brown hunting bag into his Jeep Grand Cherokee, then went to the master bedroom, where he hugged Stacy, his wife of 23 years. “I love you,” he told her.

Stacy thought that her husband was off to a job interview followed by an appointment with his therapist. Instead, he drove the 22 miles from their home in Steubenville, Ohio, to the Mountaineer Casino, just outside New Cumberland, West Virginia. He used the casino ATM to check his bank-account balance: $13,400. He walked across the casino floor to his favorite slot machine in the high-limit area: Triple Stars, a three-reel game that cost $10 a spin. Maybe this time it would pay out enough to save him.

“Well, you’re just special. You’re American,” remarked my colleague, smirking from across the coffee table. My other Finnish coworkers, from the school in Helsinki where I teach, nodded in agreement. They had just finished critiquing one of my habits, and they could see that I was on the defensive.

I threw my hands up and snapped, “You’re accusing me of being too friendly? Is that really such a bad thing?”

“Well, when I greet a colleague, I keep track,” she retorted, “so I don’t greet them again during the day!” Another chimed in, “That’s the same for me, too!”

Unbelievable, I thought. According to them, I’m too generous with my hellos.

When I told them I would do my best to greet them just once every day, they told me not to change my ways. They said they understood me. But the thing is, now that I’ve viewed myself from their perspective, I’m not sure I want to remain the same. Change isn’t a bad thing. And since moving to Finland two years ago, I’ve kicked a few bad American habits.

A professor of cognitive science argues that the world is nothing like the one we experience through our senses.

As we go about our daily lives, we tend to assume that our perceptions—sights, sounds, textures, tastes—are an accurate portrayal of the real world. Sure, when we stop and think about it—or when we find ourselves fooled by a perceptual illusion—we realize with a jolt that what we perceive is never the world directly, but rather our brain’s best guess at what that world is like, a kind of internal simulation of an external reality. Still, we bank on the fact that our simulation is a reasonably decent one. If it wasn’t, wouldn’t evolution have weeded us out by now? The true reality might be forever beyond our reach, but surely our senses give us at least an inkling of what it’s really like.

A report will be shared with lawmakers before Trump’s inauguration, a top advisor said Friday.

Updated at 2:20 p.m.

President Obama asked intelligence officials to perform a “full review” of election-related hacking this week, and plans will share a report of its findings with lawmakers before he leaves office on January 20, 2017.

Deputy White House Press Secretary Eric Schultz said Friday that the investigation will reach all the way back to 2008, and will examine patterns of “malicious cyber-activity timed to election cycles.” He emphasized that the White House is not questioning the results of the November election.

Asked whether a sweeping investigation could be completed in the time left in Obama’s final term—just six weeks—Schultz replied that intelligence agencies will work quickly, because the preparing the report is “a major priority for the president of the United States.”

Democrats who have struggled for years to sell the public on the Affordable Care Act are now confronting a far more urgent task: mobilizing a political coalition to save it.

Even as the party reels from last month’s election defeat, members of Congress, operatives, and liberal allies have turned to plotting a campaign against repealing the law that, they hope, will rival the Tea Party uprising of 2009 that nearly scuttled its passage in the first place. A group of progressive advocacy groups will announce on Friday a coordinated effort to protect the beneficiaries of the Affordable Care Act and stop Republicans from repealing the law without first identifying a plan to replace it.

They don’t have much time to fight back. Republicans on Capitol Hill plan to set repeal of Obamacare in motion as soon as the new Congress opens in January, and both the House and Senate could vote to wind down the law immediately after President-elect Donald Trump takes the oath of office on the 20th.